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Exergame: A Gamelike Exercise to Improve Motor Functions and Physical Activities in Diabetic Patients Undergoing Hemodialysis
Background: Balance mobility falls and foot problems are serious detriments for the diabetic patients undergoing hemodialysis (HD) treatment. In addition the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve mobility and balance as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve daily physical activity in diabetic patients undergoing HD treatment. Methods: Thirty-three diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 15 age = 62.2 ± 7.6 years BMI = 29.1 ± 6.1 kg/m2) and a control group (CG: n = 18 age = 66.6 ± 8.7 years BMI = 32.5 ± 9.0 kg/m2). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject played some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depends on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without technology. Daily physical activity data was assessed for 48 hours (day and night) at baseline and post 4-week exercise using a validated wearable sensor (PAMSysTM). Daily physical activity was quantified by duration spent in each main posture (i.e. lying sitting standing and walking) and activities (e.g. postural transition sedentary behavior etc). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. At the end of intervention subjects in the IG were more active than subjects in the CG. In summary the IG performed 53% more posture transitions to walking (Cohen's d effect size = 0.5) and 39% more posture transitions between sitting and walking (d = 0.5) when compared to the CG. Subjects in the IG also had significant less sedentary behavior than subjects in the CG. In summary subjects in the IG spent 5% less time on sitting and lying (p = 0.049 d = 0.7) as well as 47% more time on standing and walking (p = 0.049 d = 0.7) when compared to subjects in the CG. Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve daily physical activity in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise. Further studies should be addressed to confirm the observation with larger sample sizes.
GameBased NonWeight Bearing Exercise to Improve Postural Balance in Diabetic Patients Underjoining Hemodialysis
Background: Poor balance falls and foot problems are serious detriments for the diabetic patients due to the obesity and diabetic foot ulcer. In addition for the diabetic patients undergoing hemodialysis (HD) treatment the HD process often leaves them too fatigued to engage in any physical activity or daily exercise further deteriorating their motor functions and increasing risk of falling. Exercise would be effective for this population. However due to the time availability post-dialysis fatigue as well as limitation of transportation to exercise facility the conventional exercise for this population is impractical. Objective: We are developing an interactive foot and ankle exercise game that can be played during HD sessions to improve foot region blood flow as well as reduce foot problems. In this study we examined the feasibility and effectiveness of this innovative wearable sensor based non-weight bearing exercise (Exergame) to improve postural balance in diabetic patients undergoing HD treatment. Methods: Sixty diabetic subjects receiving HD treatment were recruited and randomized into an intervention group (IG: n = 29 age = 63.3 ± 7.9 years BMI = 31.2 ± 6.5 kg/m2 female = 41%) and a control group (CG: n = 31 age = 66.5 ± 10.7 years BMI = 32.3 ± 8.2 kg/m2 female = 55%). Both groups underwent a 4-week ankle and foot exercise program (30 minutes per session two sessions per week) during HD process. The IG received exercise via the Exergame program which uses wearable sensors attached on subject's feet. The subject's 3-dementional ankle and foot movements were visualized in real-time on a computer screen placed in front of him/her. The subject performed some game-like tasks by moving and rotating the foot and ankle. The difficulty level of the task was gradually increased depending on ability of the subject (like a game) from a simple flexion-extension movement to more complex movements including medial-lateral movement with different range of motion. The CG received traditional foot and ankle exercise without any technology. Postural balance was assessed in the semi-tandem test. Balance tests were performed at baseline and conclusion of the program under both eyes-open and eyes-closed conditions. Balance parameters included ankle sway and hip sway in anterior-posterior (AP) direction (degree) medial-lateral (ML) direction (degree) as well as in area (degree2). Results: All IG subjects achieved to complete all exercise tasks indicating the feasibility of the Exergame platform. No adverse event or difficulty were reported indicating practicality of the exercise program. None subject in the IG was dropped out during the 4-week exercise program. Low dropout rate may indicate acceptability of the proposed Exergame platform. Under eyes-open condition the IG had significant ankle sway reduction in the AP direction (Cohens’ d effect size = 0.55 p = 0.037) when comparing with the CG. At conclusion the AP direction ankle sway reduced 18% in the IG while in the CG it increased 58%. More significant improvements of postural balance were observed under eyes-closed condition. When comparing with the CG the IG had significant ankle and hip sway reductions in both AP and ML directions as well as in area (p < 0.050). The highest effect size contrasting changes between the IG and CG was also observed for ankle sway in ML direction (Cohens’ d effect size = 0.76 p = 0.005). Conclusions: This study demonstrated feasibility acceptability and effectiveness of an innovative Exergame program to improve postural balance in diabetic patients undergoing HD treatment. The key innovation of the proposed intervention is its practicality to be done during HD process which could address the limitations of prior exercise interventions in HD patients for example the low adherence of therapeutic exercise.
Applying Novel Body-Worn Sensors to Measure Stress: Does Stress Affect Wound Healing Rates in the Diabetic Foot?
Background and Aim: In the United States alone diabetic limb complications and amputations are estimated to cost $17 billion. Significant risk factors that may lead to amputation of the diabetic foot include ineffective wound healing and infection of a wound or ulcer. Previous studies have shown that wound healing is slowed and patient's susceptibility to infection is increased when a patient is under chronic stress. To date objective measures of stress have not been used to determine if stress affects the rate at which wounds heal. Our study used novel real-time monitoring of patient's heart rate variability to objectively determine the stress levels of patients visiting a surgery clinic for wound dressing changes. The wound healing rates of patients with high stress levels were compared to healing rates of low-stress individuals to assess the effect of stress on rates of wound healing among diabetics with a history of foot ulceration. Methods: Twenty patients (age: 56.7 ± 12.2 years) with diabetic foot ulcers were equipped with a chest-worn sensor (Bioharness 3 Zephyr Technology Corp. Annapolis MD) during their 45-minute appointments where the patients’ wound was re-dressed. The chest sensor contained a uni-channel ECG recorder and a novel algorithm was developed to determine heart rate variability from sensor output. Low frequency (0.04 to 0.15 Hz) HRV signals were isolated from high frequency signals (0.15 to 0.40 Hz) and the ratio of their amplitudes was used as a measure of stress. Patients were categorized as low-stress if the ratio of the signals was less than 1 and were otherwise categorized as high-stress individuals. Regardless of classification each patient's wound size (length width depth) was recorded at baseline and in follow-up visits. High and low-stress patients were compared to see if wound sizes decreased more rapidly in either group. Results: Results indicate that patients with low levels of stress reduced their wound size by 79% between baseline and the first follow-up appointment (1.36 mm3 to 0.28 mm3). In contrast patients with high levels of stress had adverse outcomes with their wound sizes increasing nearly four times between baseline and follow-up (0.17 mm3 vs 0.84 mm3). Although high stress individuals had smaller wound sizes than low stress individuals initially (0.17 mm3 vs. 1.36 mm3 p < 0.05) the wound sizes of high stress individuals were nearly 3 times larger by the first follow-up (0.84 mm3 vs. 0.28 mm3 p = 0.10). Conclusion: Our research proposes that an individual's stress level can be objectively measured using an algorithm that processes ECG data from a single body-worn sensor that is lightweight and comfortable to wear. The stress levels measured with our algorithm are predictive of positive clinical outcomes. Specifically individuals with low levels of recorded stress at baseline have faster healing rates and greater reductions in wound size by their second clinical appointment. This indicates that real-time patient stress monitoring using body-worn sensors may help clinicians identify risk factors that prolong wound healing times. In addition it can be inferred that managing stress in diabetic patients will quicken the pace of wound healing. Surprisingly however our results suggest that initial wound sizes are not good indicators of stress levels in patients during initial clinical appointments. In fact wound sizes of high stress individuals were significantly lower than low-stress individuals at baseline.
Lower Extremity Blood Flow Change From A Low Impact Virtual Reality Training In Diabetes
Background: Inadequate blood flow can increase risk of foot ulceration in diabetics. Exercise training can improve lower extremity blood flow in diabetes however the intensity of exercise should be taken into account for this population is they are at high risk for developing foot ulcers. Aim: The aim of the present study is to explore the immediate effect of a tailored low impact virtual reality exercise training on lower extremity blood flow in patients with diabetic peripheral neuropathy. We hypothesize that tailored exercise specifically designed for diabetes will induce sufficient muscle activation in order to improve blood flow. Methods: Eight patients (Age: 64.3±10.2 years BMI 32.6±6.3) with diagnosed DPN (HbA1c: 7.3±1.2) participated in a single 45 minute session for low-impact virtual reality based balance training exercise. Changes in blood flow were quantified by Ankle Brachial Index (ABI) recorded pre- and post-training. Systolic blood pressures were determined at the brachial posterior tibial and dorsalis pedis arteries using a 10 MHz handheld Doppler. Results: Non-parametric Wilcoxon Signed Rank test revealed a strong but non-significant reduction in ABI from single session virtual reality training. The values dropped from 1.28 to 1.22 (4.7% reduction p = 0.173). Conclusion: The initial results show that a tailored low impact exercises for diabetes can improve blood flow which may reduce the risk for diabetic foot ulceration. Future studies should confirm these findings in a larger pool of patients with 8-12 week exercise training in order to explore the long term effect on exercise on blood flow. Funding Source: QNRF NPRP 4-1025-3-276
Validation Of An Optical Fiber Based Smart Textile: A Clinical Tool For Predicting Diabetic Foot Ulceration
Background: Undetected repeated foot loading and temperature changes during walking in diabetic patients with peripheral neuropathy significantly increases risk of foot ulceration. Early detection of inflammation due to foot temperature and pressure changes from walking has shown to be a potentially effective strategy in prevention of foot ulcers. Therefore a clinically feasible assessment of these changes is vital to measure pre-ulcerative inflammation and predict DFUs. The current study is aimed to validate effectiveness of an innovative fiber optics embedded smart textile for simultaneous measurement of plantar pressure and temperature. Methods: The study recruited 21 diabetic patients (Age: 57.8±7.9 years BMI: 31.6±8.0 kg/m2 VPT: 26.8±15 volt 68% diagnosed with peripheral neuropathy) at high risk for foot ulcers from Wound and Diabetic Foot Center at Hamad Medical Co. Doha. A series of sensors were juxtaposed on the length of an optical fiber integrated in a comfortable sock (Novinoor LLC IL) for measuring temperature and pressure changes under anatomical regions of the heel midfoot 1st and 5th metatarsal heads and big toe based on changes in wavelength of light. A thermal image was acquired after five-minute temperature acclimation before walking for validating temperature changes. Participants walked 200 steps to induce thermal stress and follow up thermal image was acquired. Participants also wore F-scan insoles (TekScan®Inc) during walk for pressure validation. Results: All the recruited patients perceived the device as comfortable. A significant correlation was observed between both pressure (r=0.67 p<0.05) and temperature (r=0.55 p<0.05) measurements between the sock and the reference systems under different anatomical regions of interest. Conclusion: This study demonstrates the proof of concept for an innovative smart textile in simultaneous assessment of the key parameters associated with risk of foot ulcer in patients with diabetes. Given the correlation values additional studies will larger sample size is required to further validate and address whether the technology can predict and better manage diabetic foot ulcers. Funding source: NPRP 4-1026-3-277